Basic Information
| Provider Information | |||||||||
| NPI: | 1982023669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIAUTAUD | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 DUNDEE RD | ||||||||
| Address2: | SUITE 704 | ||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600622437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474985437 | ||||||||
| FaxNumber: | 8475985438 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 DUNDEE RD | ||||||||
| Address2: | SUITE 704 | ||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600622437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474985437 | ||||||||
| FaxNumber: | 8475985438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-15820 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.